Receptor-Independent Therapies for Forensic Detainees with Schizophrenia-Dementia Comorbidity.

Forensic institutions throughout the world house patients with severe psychiatric illness and history of criminal violations. Improved medical care, hygiene, psychiatric treatment, and nutrition led to an unmatched longevity in this population, which previously lived, on average, 15 to 20 years shorter than the public at large. On the other hand, longevity has contributed to increased prevalence of age-related diseases, including neurodegenerative disorders, which complicate clinical management, increasing healthcare expenditures. Forensic institutions, originally intended for the treatment of younger individuals, are ill-equipped for the growing number of older offenders. Moreover, as antipsychotic drugs became available in 1950s and 1960s, we are observing the first generation of forensic detainees who have aged on dopamine-blocking agents. Although the consequences of long-term treatment with these agents are unclear, schizophrenia-associated gray matter loss may contribute to the development of early dementia. Taken together, increased lifespan and the subsequent cognitive deficit observed in long-term forensic institutions raise questions and dilemmas unencountered by the previous generations of clinicians. These include: does the presence of neurocognitive dysfunction justify antipsychotic dose reduction or discontinuation despite a lifelong history of schizophrenia and violent behavior? Should neurolipidomic interventions become the standard of care in elderly individuals with lifelong schizophrenia and dementia? Can patients with schizophrenia and dementia meet the Dusky standard to stand trial? Should neurocognitive disorders in the elderly with lifelong schizophrenia be treated differently than age-related neurodegeneration? In this article, we hypothesize that gray matter loss is the core symptom of schizophrenia which leads to dementia. We hypothesize further that strategies to delay or stop gray matter depletion would not only improve the schizophrenia sustained recovery, but also avert the development of major neurocognitive disorders in people living with schizophrenia. Based on this hypothesis, we suggest utilization of both receptor-dependent and independent therapeutics for chronic psychosis.

Let's lower the floor: Clinical utility of the D-KEFS TMT with a forensic psychiatric inpatient population.

Trail-making tests are widely used as part of neuropsychological assessments, although the prevalence of processing speed deficits in schizophrenia spectrum disorders may limit their utility when administered to this population. In response, our study sought to explore D-KEFS TMT performance among a forensic-oriented schizophrenia spectrum sample, with the goal of generating normative data to enhance the utility of the TMT with this population. Archival data was collected from a sample of patients admitted to a forensic maximum-security psychiatric facility. Analyses revealed a large percentage of individuals achieved an "impaired" result across D-KEFS TMT trials, ranging from 20% to more than 60%. The most noteworthy finding was for Number-Letter Switching, in which approximately 48% of participants performed at the floor level. Following reclassification of performance, 36% of our sample were identified as "below average," while greater than 60% of individuals were captured as average to above average. The current analyses revealed a problematic skew in TMT performance among schizophrenia spectrum patients, in turn complicating interpretation of cognitive status as well as the ability to compare performance between patients and over time. The present adjustments account for this skew and yield more variability in standardized scoring.